Provider Demographics
NPI:1003986407
Name:BLACK, LEORA ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:LEORA
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 COUNTRY MDWS
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-7072
Mailing Address - Country:US
Mailing Address - Phone:802-264-5333
Mailing Address - Fax:802-264-5338
Practice Address - Street 1:525 HERCULES DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5993
Practice Address - Country:US
Practice Address - Phone:802-264-5333
Practice Address - Fax:802-264-5338
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006789Medicaid